The troubled

history of the
foreskin
Common in the US, rare in
Europe and now championed in
Africa, male circumcision is hotly
debated. Jessica Wapner
explores whether the gains are
worth the loss.
24 February 2015

On a recent Saturday morning, Craig Adams

stood outside the Robert Wood Johnson
University Hospital in New Brunswick, New
Jersey. It was sunny but cold. Adams, who
had turned 40 the day before, wore white
sneakers and a black T-shirt over a longsleeve shirt. A fuzz of thinning hair capped
his still-youthful face. His appearance would
have been unremarkable if not for the red
splotch of fake blood on the crotch of his
white trousers. The stain had the intended
effect: drivers rounding the corner were
slowing down just enough to see the sign he
was holding, which read No Medical Excuse
for Genital Abuse.
Next to him, Lauren Meyer, a 33-year-old

mother of two boys, held another sign, a

white poster adorned only with the words:
Dont Cut His Penis. She had on a white
hoodie with a big red heart and three red
droplets, and a pair of leopard-print slipperboots to keep her feet warm for the several
hours she would be outside. Meyers first son
is circumcised; she sometimes refers to
herself as a regret mother for having
allowed the procedure to take place.
It was two days after Christmas. Adams and
Meyer had each driven about an hour to
stand by the side of a road holding up signs
about penises. On that same day, a woman
stood alone at what qualifies as a busy
intersection in the small town of Show Low,
Arizona. She also wore white trousers with a
red crotch, and held aloft anti-circumcision
signs. A few more people did the same in the
San Francisco Bay area.
The protests were triggered by a recent
event, but the issue at stake was an ancient
one. Circumcision has been practised for
millennia. Right now, in America, it is so
common that foreskins are somewhat rare,
and may become more so. A few weeks
before the protests, the Centers for Disease
Control and Prevention (CDC) had suggested
that healthcare professionals talk to men and
parents about the benefits of the procedure,
which include protection from some sexually
transmitted diseases, and the risks, which
the CDC describes as low. But as the

protesters wanted drivers to know, there is

no medical consensus on this issue.
Circumcision isnt advised for health reasons
in Europe, for instance, because the benefits
remain unclear. Meanwhile, Western
organisations are paying for the circumcision
of millions of African men in an attempt to
rein in HIV a campaign that critics say is
also based on questionable evidence.
Men have been circumcised for thousands of
years, yet our thinking about the foreskin
seems as muddled as ever. And a close
examination of this muddle raises disturbing
questions. Is this American exceptionalism
justified? Should we really be funding mass
circumcision in Africa? Or by removing the
foreskins of men, boys and newborns, are we
actually committing a violation of human
rights?

2__In-theflesh_GemmaTickle-andKate-Jackling.jpg

 Gemma Tickle at East Photographic

The tomb of Ankhmahor, a high-ranking

official in ancient Egypt, is situated in a vast
burial ground just outside Cairo. A picture of
a man standing upright is carved into one of
the walls. His hands are restrained, and
another figure kneels in front of him, holding
a tool to his penis. Though there is no
definitive explanation of why circumcision
began, many historians believe this relief,
carved more than four thousand years ago, is
the oldest known record of the procedure.
The best-known circumcision ritual, the
Jewish ceremony of brit milah, is also
thousands of years old. It survives to this
day, as do others practised by Muslims and
some African tribes. But American attitudes
to circumcision have a much more recent
origin. As medical historian David Gollaher
recounts in his book Circumcision: A History
of the Worlds Most Controversial Surgery,
early Christian leaders abandoned the
practice, realising perhaps that their religion
would be more attractive to converts if
surgery wasnt required. Circumcision
disappeared from Christianity, and the
secular Western cultures that descended
from it, for almost two thousand years.
Then came the Victorians. One day in 1870, a
New York orthopaedic surgeon named Lewis
Sayre was asked to examine a five-year-old
boy suffering from paralysis of both legs.
Sayre was the picture of a Victorian

gentleman: three-piece suit, bow tie, mutton

chops. He was also highly respected, a
renowned physician at Bellevue Hospital,
New Yorks oldest public hospital, and an
early member of the American Medical
Association.
After the boys sore genitals were pointed out
by his nanny, Sayre removed the foreskin.
The boy recovered. Believing he was on to
something big, Sayre conducted more
procedures. His reputation was such that
when he praised the benefits of circumcision
which he did in the Transactions of the
American Medical Association and elsewhere
until he died in 1900 surgeons elsewhere
followed suit. Among other ailments, Sayre
discussed patients whose foreskins were
tightened and could not retract, a condition
known as phimosis. Sayre declared that the
condition caused a general state of nervous
irritation, and that circumcision was the cure.
His ideas found a receptive audience. To
Victorian minds many mental health issues
originated with the sexual organs and
masturbation. The connection had its roots in
a widely read 18th-century treatise entitled
Onania, or the Heinous Sin of Self-Pollution,
and All Its Frightful Consequences, in Both
Sexes, Considered. With Spiritual and
Physical Advice to Those Who Have Already
Injurd Themselves By This Abominable
Practice. The anonymous author warned that
masturbation could cause epilepsy, infertility,

a wounded conscience and other problems.

By 1765 the book was in its 80th printing.
Later puritans took a similar view. Sylvester
Graham associated any pleasure with
immorality. He was a preacher, health
reformer and creator of the graham cracker.
Masturbation turned one into a confirmed
and degraded idiot, he declared in 1834.
Men and women suffering from otherwise
unlabelled psychiatric issues were diagnosed
with masturbatory insanity; treatments
included clitoridectomies for women,
circumcision for men.
Grahams views were later taken up by
another eccentric but prominent thinker on
health matters: John Harvey Kellogg, who
promoted abstinence and advocated foreskin
removal as a cure. (He also worked with his
brother to invent the cornflake.) The
operation should be performed by a surgeon
without administering anesthetic, instructed
Kellogg, as the brief pain attending the
operation will have a salutary effect upon the
mind, especially if it be connected with the
idea of punishment.
Counter-examples to Sayres supposed
breakthrough could be found in operating
theatres across America. Attempts to cure
children of paralysis failed. Men, one can
assume, continued to masturbate. It
mattered not. The circumcised penis came to
be seen as more hygienic, and cleanliness
was a sign of moral standards. An 1890

journal identified smegma as infectious

material. A few years later, a book for
mothers Confidential Talks on Home and
Child Life, by a member of the National
Temperance Society described the foreskin
as a mark of Satan. Another author
described parents who did not circumcise
their sons at an early age as almost
criminally negligent.
By now, the circumcision torch had passed
from Sayre to Peter Charles Remondino, a
popular San Diego physician descended from
a line of doctors that stretched back to 14thcentury Europe. In an influential 1891 book
about circumcision, Remondino described the
foreskin as a malign influence that could
weaken a man physically, mentally and
morally; to land him, perchance, in jail or
even in a lunatic asylum. Insurance
companies, he advised, should classify
uncircumcised men as hazardous risks.
Further data came from studies of the
Hebrew penis, which showed a superior
cleanliness that had protective benefits,
according to John Hutchinson, an influential
surgeon at the Metropolitan Free Hospital of
London. Hutchinson and others noted that
Jews had lower rates of syphilis, cancer and
mental illness, greater longevity, and fewer
stillbirths all of which they attributed to
circumcision. Remondino agreed, calling
circumcision the real cause of differences in
longevity and faculty for enjoyment of life

that the Hebrew enjoys.

By the turn of the 20th century the Victorian
fear of masturbation had waned, but by then
circumcision become a prudent precaution,
and one increasingly implemented soon after
birth. A desire to prevent phimosis, STDs and
cancer had turned the procedure into medical
dogma. Antiseptic surgical practices had
rendered it relatively safe, and anaesthesia
made it painless. Once a procedure for the
relatively wealthy, circumcision had become
mainstream. By 1940, around 70 per cent of
male babies in the United States were
circumcised.
In the decades since, medical practice has
come to rely increasingly on evidence from
large research studies, which, as many
American doctors see it, have supported the
existing rationale. When the CDC made its
recent statement, for example, it cited
studies showing that circumcision reduces
the risk of urinary tract infection, several
STDs, penile cancer, phimosis, balanitis
(inflammation of the foreskin and head of the
penis) and HIV. The CDC even noted benefits
for women with circumcised partners, namely
a lower risk of cervical cancer linked to
human papillomavirus.
The mechanism behind these benefits is
simple: the warm and moist region under the
foreskin can house the bacteria and viruses
that cause disease. A circumcised penis cant
be colonised so easily; without the blanket,

its harder to hide. Circumcision also removes

a large quantity of Langerhans cells, a
component of the immune system that,
according to some research, is targeted by
HIV.
During the second half of the last century, an
accumulation of studies demonstrated the
beneficial impacts of these mechanisms. At
times the research helped all but end the
debate over circumcision. By the 1970s, for
instance, more than 90 per cent of US men
were circumcised, according to one study.
The American foreskin had become a thing of
the past.

3__In-theflesh_GemmaTickle-andKate-Jackling.jpg

 Gemma Tickle at East Photographic

Today circumcision is among the most

common surgeries in the US: an estimated
1.2 million infants are circumcised each year,
at a cost of up to $270 million. Its popularity
has fluctuated since the peak of the 1970s;
the CDCs most recent estimate puts the
current rate at 60 per cent of newborns. This
may in part be because the American
Association of Pediatrics (AAP) for a time
equivocated over the issue. But in 2012 the
AAP announced that benefits of circumcision
outweighed the risks, suggesting that rates
may rise again.
Yet whether its 60 or 90 per cent of
American men who are circumcised, whats
more remarkable is that American parents
are almost alone in the Western world in their
desire to separate boys from their foreskins
for reasons other than religion. This
difference of opinion is decades old. It began
in 1949, when a British paediatrician and
scientist named Douglas Gairdner published
the first investigation of the rationale for
circumcision in English-speaking countries.
He found the procedure to be unwarranted.
Phimosis, the condition Sayre held
responsible for so many neuroses, was
essentially a non-issue, said Gairdner. He
discovered something that had somehow
gone undocumented before: that most
foreskins remain unretracted well into the
toddler years. Phimosis is the natural state of

the penis, Gairdner concluded. (Later work

would confirm that the foreskin sometimes
does not fully retract until the teenage
years.) This was just the beginning. Gairdner
showed that balanitis and posthitis, forms of
inflammation that were considered cause for
circumcision, were uncommon. He found no
data to show that circumcision could prevent
venereal diseases and little evidence for a
lesser risk of cervical cancer. Cleaning the
intact foreskin would do as much to thwart
penile cancer as would removing it, he
added.
At the National Health Service, which was
founded a year before Gairdners paper
appeared, officials heeded his advice and
refused to cover circumcision unless it was
medically necessary. By 1958, the
circumcision rate in the United Kingdom had
fallen to close to 10 per cent. Excluding
British men who are circumcised for religious
reasons, the rate is now 6 per cent or lower.
The situation is much the same elsewhere in
Europe. The Victorian focus on circumcision
was concentrated in English-speaking
countries, and its popularity never spread.
When European experts examine the
evidence, they generally see no reason that it
should. In 2010, for instance, the Royal Dutch
Medical Association reviewed the same
studies the AAP looked at. Aside from
preventing urinary tract infections, which can
be treated with antibiotics, it concluded that

the health benefits of circumcision are

questionable, weak, and likely to have little
public health relevance in a Western
context.
How can experts who have undergone similar
training evaluate the same studies and come
to opposing conclusions? Ive spent months
scrutinising the medical literature in an
attempt to decide which side is right. The
task turned out to be nearly impossible.
Thats partly because there is so much
confused thinking around the risks and
benefits of circumcision, even among trained
practitioners. But its also because, after
reading enough studies, I realised that the
debate doesnt have a scientific conclusion. It
is impossible to get to the bottom of this
issue because there is no bottom.
Assessing the true risks of circumcision is the
first challenge. Immediate complications are
usually easily treatable, and also relatively
rare the AAP report states that problems
like bleeding and infection occur in up to 1 in
100 circumcisions. But the frequency of later
problems is less well understood. Some
studies find few; others conclude that as
many as one in four patients suffer some kind
of complication after the surgery and
subsequent wound healing. The possible late
problems are many. The remaining foreskin
tissue can adhere to the penis. The opening
of the urethra may narrow, making urination
painful and preventing the bladder from fully

emptying, which in turn can lead to kidney

problems. Craig Adams, the New Jersey
protester, had to have surgery to correct
such a problem when he was five years old.
Lauren Meyers first son had surgery for the
same reason when he was three. Other late
complications include a second surgery to
correct an incomplete circumcision, a rotated
penis, recurrent phimosis, and concealment
of the penis by scar tissue, a condition
commonly known as buried penis.
The AAP acknowledges some uncertainty
surrounding the data on risks, but not in a
way that a parent looking for advice is likely
to fully grasp. The true incidence of
complications after newborn circumcision is
unknown, the AAPs recent report states.
But complications are risks. Theyre saying,
The benefits outweigh the risks but we dont
know what the risks are, says Brian Earp,
research fellow at Oxford Universitys Uehiro
Centre for Practical Ethics. This is basically
an unscientific document.
The debate about the effectiveness of
circumcision can be just as convoluted. One
way of thinking about this is the number
needed to treat (NNT), a figure that answers
the question: how many people need to be
treated with this approach in order to prevent
one illness? For the ideal treatment the
answer is one. But penile cancer is rare and
circumcision doesnt provide complete
protection against it, so around 900

circumcisions are needed to prevent a single

case. Thats a very high NNT. By comparison,
50 people need to take aspirin to prevent one
cardiovascular problem.
Its also worth noting that other preventive
methods can have a greater impact on penile
cancer. The American Cancer Society
suggests avoiding smoking, for example. The
same logic applies to sexually transmitted
diseases. Studies show that circumcision
reduces the chances of a man contracting
herpes, for example. But the risk of this and
every known STD can be stopped or at least
dramatically reduced by correct and
consistent condom use. The benefits can all
be obtained in other ways, says Adrienne
Carmack, a Texas-based urologist who
opposes routine infant circumcision.
Even the premise behind this debate that
the usefulness of circumcision can be
determined by weighing the risks and
benefits is questionable. A drug for a deadly
disease has a lot of leeway in terms of sideeffects. Cancer patients are willing to endure
chemotherapy if it means they get to live, for
example. But when the person is healthy and
too young to weigh the risks and benefits
themselves, the maths changes. Your
tolerance for risk should go way down
because its done without consent and its
done without the presence of disease, says
Earp.
These uncertainties undermine the case for

circumcision. They dont completely destroy

it though. Even after the criticisms are
factored in, circumcision does bring some
benefits, such as reducing the risk of urinary
tract infections in young boys. What the
uncertainties do is raise questions about
whether those benefits justify the procedure.
And this is where an evidence-based
approach breaks down. Because the
procedure results in the loss of something
whose value cannot be quantified: the
foreskin. If you view the foreskin as
disposable, circumcision might be worth it.
For those who see the act as the removal of a
valuable body part, the reverse is likely true.
More than the medical data, its these
unquantifiable feelings about the foreskin
that shape doctors thinking about
circumcision, or at least that of male doctors.
Because when it comes to medical opinions
on circumcision, the foreskin status of the
opiner matters. A 2010 survey in the Journal
of Mens Health found that close to 70 per
cent of circumcised male physicians
supported the procedure. An almost identical
fraction of uncircumcised physicians were
opposed. The AAP Task Force behind the
2012 statement was made up mainly of men,
all of whom were circumcised and from the
US, where newborn circumcision is the
norm. Seen from the outside, cultural bias
reflecting the normality of nontherapeutic
male circumcision in the United States seems

obvious, wrote a group of European

physicians in response to the AAP.
Its also likely that most of these critics were
not circumcised. We never deny that we are
from a non-circumcising culture, said Morten
Frisch, lead author of the response and an
epidemiologist who studies sexual health at
Statens Serum Institut in Denmark. While
we claim that the US view is culturally
biased, the opposing view from the AAP was
that its us who are culturally biased, and to
an extent they are right.
These cultural divisions make it nearly
impossible to sort through the medical
literature. Rather than clarifying, the debate
gets bogged down in accusations of poor
research and bias. Brian Morris, a molecular
biologist at the University of Sydney who is
an outspoken proponent of circumcision,
recently circulated a 23-page critique of a
study by Frisch. The Danish researchers work
was an ideological rant against male
circumcision, said Morris, who asked
colleagues to complain to the journal that
published it. In response, Frisch called out
Morris for citing his own pro-circumcision
manifesto as source material for his critique
and, in a video response on YouTube, said
that Morris had accused us of racism and
dishonesty and all sorts of things in order
to have the editors reject the paper.
Both sides tend to be highly selective on
which bits of evidence they want to quote,

says Basil Donovan, an epidemiologist

focused on sexual health at the University of
New South Wales and a community-based
infectious disease physician. Professional
discussions have become so heated that
Donovan rarely participates. I stay out of the
area, he said. I want to have a life, I dont
want people bombing the front door.

None of this is much help to a circumcised

man who is wondering about a body part he
never knew. Then again, many circumcised
men want to know something besides the
health benefits. They want to know whether
removal of the foreskin negatively impacts
sex.
Some of the most compelling data in this
area came from a pathologist named John
Taylor, who in 1996 published the first
description of the cells that make up the
foreskin. An uncircumcised Englishman,
Taylor was initially motivated by the prospect
of his Canada-born children being
circumcised. Thats what led him to examine
the foreskins of 22 uncircumcised corpses.
He wanted to know whether the tissue had
any functional value if foreskin cells are
specialised and serve some particular
purpose, Taylor reasoned, that should be
weighed when considering circumcision.
Specialised cells were exactly what Taylor
found. Measuring about 6.5 centimetres long
when fully grown, the foreskin is a mucosal

membrane that contains copious amounts of

Meissners corpuscles, touch-sensitive cells
that are also present in our lips and
fingertips. We only find this sort of tissue in
areas where it has to perform specialised
function, Taylor later told an interviewer
from Intact Canada, an organisation seeking
to end circumcision. The mucosal inner
surface is kept wet by a natural lubricant,
and the tip contains elastic fibres that allow it
to stretch without becoming slack. This is
sexual tissue, and theres no way you can
avoid the issue.
One of Taylors most noteworthy discoveries
was the ridged band, an accordion-like strip
of flesh about 10 to 15 millimetres long that
is as sensitive as the fingertips. During an
erection, the band is turned inside out,
placing highly sensitive cells at the base of
the penis. In later work, Taylor and a
colleague described the band as far more
sensitive than the glans, the part of the penis
left exposed after circumcision. The only
portion of the body with less fine-touch
discrimination than the glans penis is the
heel of the foot, they wrote. The penis still
works without a foreskin, of course. But the
foreskin is erogenous tissue. It also keeps the
penis protected and moist. Without it the
exposed surface is smoother, drier, more
sensitive to changes in temperature and
more easily irritated by clothing. A thickening
of the surface of the glans, known as

keratinisation, can also decrease sensitivity.

Foreskin cells dont grow back. Efforts to
restore the foreskin by pulling the flesh
downwards a practice attempted by some
men whove experienced sexual problems or
who simply dislike having had their foreskin
removed without their say can create an
overhang of skin, but cant replace the
sensitive cells. Taylor, who died in 2010,
believed that the foreskin is as important as
the glans to sexual function. Doctors doing
this procedure dont know what theyre
removing, he told Intact Canada.
If Taylor is right, circumcised men should
have less sensitive penises. One way to test
that idea is to touch a lot of penises,
circumcised and not, in a laboratory setting.
At least one group has done so. In 2006, a
team of US scientists and anti-circumcision
activists used stiff nylon thread to measure
the sensitivity of 19 points on the foreskin
(when present) and glans of almost 160 men.
The most sensitive spot on circumcised men
was the circumcision scar; in uncircumcised
men, it was the foreskin.
Many men also wonder if circumcision leads
to sexual problems. Again theres tentative
evidence that it does. In 2011, Morten Frisch
published data on the sexual experiences of
more than 5,500 men and women. (This was
the study disputed by Brian Morris.) Few
people reported problems, but of those who
did trouble achieving orgasm, for instance,

or, for women, pain during sex most were

circumcised men or their female partners.
Another opportunity to study the question
arose when widescale circumcision was
introduced in South Korea around 1950,
largely as a result of the US presence there in
the years after World War II. Researchers at
Seoul National University asked recently
circumcised men about sexual function
before and after the procedure. Of the
approximately 140 men who were sexually
active before and after the surgery, nearly
half said masturbation was now less
pleasurable. Of the 28 men from this group
who said sex was also now less enjoyable,
most attributed the difference to a decrease
in sensation.
Still, these data are far from conclusive, and
other researchers have reached the opposite
conclusion. Morris, the circumcision
advocate, reviewed 36 studies,
encompassing a total of around 40,000 men,
and found no impairment in sensitivity,
orgasm achievement, erectile function or any
other measure of sexual function connected
to circumcision. And so the debate goes on,
offering little clarity to the people who need it
most: parents wondering if they should
circumcise their newborn sons.

4__In-the-

flesh_GemmaTickle-andKate-Jackling.jpg

 Gemma Tickle at East Photographic

All of this the benefits, the harms, the bias,

the anger could justify a randomised clinical
trial of circumcision. These experiments are
the surest way to judge the usefulness of a
treatment, and could eliminate the angst
over the decision. Yet circumcision has never
been the subject of one. Its hard to see that
changing. American parents would
presumably be happy to have such a study to
inform their thinking, but few would want
their babies take part in it.
Actually, that point about trials isnt entirely
accurate: there have been randomised
controlled trials of circumcision three, to be
exact. Just not in America. The studies took
place in Uganda, Kenya and South Africa
between 2002 and 2006. Their primary
purpose was to determine whether
circumcision reduces the risk of HIV
transmission from women to men during sex.
Each was large, involving around 3,000
subjects, and lasted around two years. Adult
volunteers were randomly assigned to be
circumcised or not, and the circumcised men
ended up with fewer cases of HIV. Follow-up
analyses have confirmed that the protective
benefits persist.
This was big news in a region living through
some of the worst of the AIDS epidemic. In
South Africa, for example, around 6 million
people are HIV-positive. The studies
suggested that circumcision could reduce the

risk of a man in the region acquiring HIV from

heterosexual sex by 60 per cent. Based on
this, a 2007 analysis estimated that if every
man in sub-Saharan Africa were circumcised
over a five-year period, countries in the
region could cut their HIV rates from 12 per
cent to 6 per cent by 2020.
Once the potential became clear donors
decided to attempt something almost as
ambitious. In 2007, the United States Agency
for International Development (USAID) and
the Bill & Melinda Gates Foundation, together
with other donor organisations, launched a
$1.5 billion campaign to circumcise 80 per
cent of boys and men across and southern
Africa by the end of this year, a total of about
20 million people.
EXTRA

Circumcising Zimbabwe
From mass media to tribal ritual, campaigners are
using circumcision to fight HIV in Zimbabwe. By Jessica
Wapner.

One afternoon last July I watched the final

stages of this extraordinary campaign play
out in Iringa, a city in the southern highlands
of Tanzania. A pick-up loaded with a DJ and
booming sound system was parked at a dirt
crossroad bordered by concrete shops and
lean-tos covered in corrugated metal. A
young woman peer promoter was her job
title spoke through a microphone. She wore
a black T-shirt with tohara, the Swahili word
for circumcision, across the front. A crowd

gathered, and she asked circumcised

onlookers to give testimonials about the
importance of the procedure. Barefoot
children sat listening on fence posts and
danced to the music when the peer promoter
took a break.
This was a demand-creation activity an
outreach effort designed to generate interest
in circumcision. Iringans had good reason to
be interested. Sixteen per cent of the local
population have HIV, partly because truckers
overnight there, and prostitution near the
truck stops is common. Jhpiego, a nonprofit
health organisation affiliated with Johns
Hopkins University that was running the
event, has placed circumcision clinics at
health facilities in the area, advertised on the
radio and posted giant billboards at heavytraffic intersections.
In the crowd listening to the lessons on
tohara I met Violet Msuya, a 21-year-old
student holding her niece on her hip. I want
my man to be clean, she said through a
translator when I asked about her interest. If
that man is clean, it will help me avoid
cervical cancer and HIV. She told me that
she hadnt had sex with an uncircumcised
man, but had heard from friends that a
foreskin makes sex less pleasant.
Later that day, at one of Iringas larger
hospitals, I talked with Gabriel, a 20-year-old
who was about to be circumcised.
Circumcision will reduce my chance of being

infected with HIV by 60 per cent, he told me.

He added that it would be easier for him to
stay clean without a foreskin, and said hed
heard through the media that circumcision
could reduce his risk of cancer.
It was his second visit to the hospital. Gabriel
had chickened out the first time, but
mustered the courage to return after
discovering he could be circumcised with a
device known as PrePex, a circular clamp that
is applied to the penis. He sat on an
operating table as Dennis Fischer, the clinics
physician, demonstrated the health benefits
of circumcision for me using a wooden dildo
covered with a brown felt foreskin. Gabriel
was still sitting on the table when I left, his
thin, jean-clad legs dangling over the side,
awaiting the PrePex. In a few days, he would
return to have the clamp removed and the
dead flesh cut off.
Before the campaign, Tanzania, which is
home to over 100 ethnic groups, had a mixed
prevalence of circumcision. Some groups, like
the Maasai, practised traditional
circumcision. So did the countrys Muslims.
Others, including the Christian population,
had rarely done so. Changing that required
millions of dollars in infrastructure and
salaries, and a collision with a variety of
beliefs. Men feared circumcision would leave
them impotent, or automatically convert
them to Islam. Parents worried that their
sons penises would not grow. When the

programme first began, there were rumours

about discarded foreskins being ground up
for use in meat stock in America, or being
sent to Europe to make cosmetics. Even the
countrys administration was resistant. It
took two years to convince government
officials, says Sifuni Raphael Koshuma, a
surgeon from Dar es Salaam who leads the
PrePex research.
Since then, organisations like Jhpiego have
been so successful that circumcision is now
fashionable. Even married couples embrace
it. After visiting Iringa I drove out to Usokami,
a rural clinic where the mud houses have no
electricity or running water and bicycles are
more common than cars. At the clinic I met
Meshak Msigwa, 42, who told me his wife had
encouraged him to get circumcised. He spoke
to me from behind a blue hospital curtain,
and his sentences were punctuated by the
metallic click of scissors as a doctor snipped
off his foreskin. I asked him if having the
surgery implied that he or his wife both are
HIV-negative would cheat. He told me that
wont happen. I swore in church I would be
faithful to my wife, he said.
The goal of circumcising 80 per cent of men
and boys over the age of ten in Iringa is
nearly accomplished. Jhpiego is now
conducting what the programme
administrators refer to as a mop-up,
targeting specific clinics where the total
number of circumcisions has been low. The

organisation is also promoting routine early

infant medical circumcision. In Tanzania and
other countries in Africa, as in America, the
foreskin is becoming a thing of the past.
There is another similarity between the
situation in Africa and that in America: in
both cases, the scientific evidence for
circumcision is less certain than advocates
make out. A 60 per cent risk reduction is a
long way from total protection, for one thing.
Michel Garenne, an epidemiologist at the
Pasteur Institute in Paris, notes that many
interventions with that kind of efficacy an
early version of the cholera vaccine, the
rhythm method as contraception have not
been recommended as wide-scale public
health measures because the benefits dont
translate to a broad population that is
repeatedly exposed to infection. The same is
true of HIV: a man who repeatedly has sex
without a condom runs a high risk of
contracting the virus, regardless of his
circumcision status. If the randomised
controlled trials had shown 99 per cent
efficacy, that would be one thing, says
Garenne. But they havent.
There is also a problem with the information
given to those who volunteer for surgery. I
met many newly circumcised men who
repeated what Gabriel had heard:
circumcision reduces the risk of contracting
HIV by 60 per cent. Yet this figure is what
epidemiologists call the relative risk

reduction. It tells us that in the clinical trials

there were 60 per cent fewer new HIV
infections among the circumcised men than
the uncircumcised group. It says nothing
about the actual risk of contracting HIV. That
risk depends very much on sexual behaviour.
Critically, if men have frequent sex with
infected women they will likely get HIV,
regardless of whether they are circumcised.
Its also crucial, but perhaps not appreciated
by all volunteers, that circumcision does not
reduce the chances of an HIV-positive man
infecting his female partner.
The campaign organisers know all of this, of
course. Its one reason why every man who is
circumcised is also counselled in the ABCs of
HIV prevention: Abstinence, Being faithful
and Condom use. The campaign
administrators also talk of condom fatigue.
They know that men will forgo condoms on
occasion, and circumcision reduces the risk
when they do. Its a single, one-off
procedure, says Ronald Gray, of Johns
Hopkins University, who led the trial in
Uganda. Because the benefit, however large
or small, is conferred for life, its worth it,
Gray argues.
Still, no one knows what the level of
protection will be outside the confines of the
clinical trials, in which volunteers were
counselled and tested for HIV every few
months, receiving money at each clinic visit.
The impact of circumcision on HIV rates

among women is particularly hard to predict,

and its possible that the procedure could
confer a false sense of protection on
circumcised men. My impression is the
campaign is as likely to have a positive effect
as a negative effect, says Garenne. Well
know in 20 years.
Transitioning to routine early infant
circumcision, as is happening in Tanzania and
a few other locations, is also controversial.
The evidence in adults is also true for
infants, says Emmanuel Njeuhmeli, a senior
USAID official working on the circumcision
campaign. But so far we only have data on
adult circumcision. In the absence of better
evidence, should governments be
recommending a surgical procedure to
citizens who are too young to agree to the
procedure? Its highly questionable in terms
of medical ethics, says Garenne.
Such concerns arent likely to have much
impact, because the thinking about
circumcision in Africa is settled for now. The
procedure is voluntary, but opting out is
getting harder. Radio advertisements
persuade men that circumcised penises are
cleaner and sexier. Food vouchers are
sometimes used as incentive to get
circumcised. Its really increasingly
becoming a sort of socially coerced activity,
says Oxfords Brian Earp. Thats not
voluntary any more. Njeuhmeli isnt sure
thats a problem. If circumcision can help halt

HIV, why not stigmatise foreskins? When

you reach 80 per cent coverage, the
remaining 20 per cent of men are definitely
being stigmatised, he says. Is it a bad
stigma or a good stigma? I honestly dont
know.

If I were a new mother in a country hit hard

by HIV, I would at least strongly consider
having my infant son circumcised. There are
uncertainties, but if circumcision can put a
dent in the epidemic, then I understand why
parents would look at the evidence and
choose the procedure. In the United States
the picture is less clear. HIV rates here are
much lower and the route of transmission is
usually not heterosexual sex. What should
parents do?
After reading the literature, Im unconvinced
by the evidence used to justify circumcision
for health reasons. Ill explain why by means
of a thought experiment. Imagine that infant
male circumcision had never been a part of
American medical practice, but was common
in, say, Spain or Senegal or Japan. Based on
what we know about the health benefits of
the procedure, would American doctors
recommend introducing the procedure? And
would that evidence be enough for American
parents to permanently remove a part of
their childs body without his agreement?
Remember what the evidence tells us. Either
the benefits can be obtained by a milder

intervention (antibiotics and condoms in the

case of urinary tract infections and sexually
transmitted diseases), or the risk is low and
open to other preventive measures (penile
cancer), or the concern is rarely justified (HIV
in the United States). Remember also that
Western countries where circumcision is rare
do not see higher rates of the problems that
foreskin removal purports to prevent: not
STDs, not penile cancer, not cervical cancer,
not HIV. Its hard to imagine circumcision
being introduced on this basis. Its equally
difficult to picture studies on the benefits of
the procedure being done.
The main reason we have circumcision in the
US today is not the health benefits. Its
because were used to it. After all, if
circumcision is not definitively preventing a
life-threatening issue that cannot be
prevented by other means, can removal of a
body part without the agreement of the child
be justified? We are so accustomed to the
practice that operating on an infant so that
he resembles his father seems acceptable.
Ive heard many people give this as their
reason. It isnt a good one.
Its disconcerting to think that circumcising
infant boys may be a violation of their human
rights. We castigate cultures that practise
female genital mutilation (FGM). Rightfully
so: no one should be coerced into such a
violation. But removal of the clitoral hood,
one form of FGM, is anatomically analogous

to removal of the foreskin. Some forms of

FGM, such as nicking or scratching the
female genitalia, are unequivocally deemed a
human rights violation but are even milder
than the foreskin removal done in US
hospitals.
Thinking about male circumcision as an
unnecessary and irreversible surgery forced
on infants, I cant but hope that the troubled
history of the foreskin will come to an end,
and that the foreskin will be known for its
presence rather than its absence. I
understand why some people demand an
immediate end to circumcision. And I
understand why a man would stand on a
street corner for hours on a cold day wearing
red-stained trousers, angry at what was done
to him without his agreement and trying to
prevent other men from suffering the same
fate.